· Administer leadership support to department managers in the execution and oversight of Utilization Management and department activities. · Strategically plan long and short-term goals, policies, and procedures for each department. Establish strong performance-based relationships. Navigate through roadblocks and barriers to success. Develop processes and protocols to ensure continued sustainability of initiatives and business processes. · Determine the effectiveness of health services programs and offer expert advice to modify accordingly. · Coordinate with HR to actively find candidates, including department managers, to develop and promote from within the departments. · Direct the research efforts in defining company third party billing procedures and in preparation of written third party billing procedures. Research and respond to company procedural questions from managers and management staff from other departments.· Oversee monthly financial reports for operational areas validating the reports and preparing explanations for variances. · Manage the gathering, evaluation, and management of qualitative and quantitative data supporting utilization outcomes, managed care outcomes, quality and overall program effectiveness in accordance to company standards and any other applicable quality and CMS standards and regulations. · Utilize timely and meaningful financial and utilization reports to assist providers in efforts to alter their care delivery patterns, improve member outcomes, and further the success of the program within the framework of the organization’s annual goals. · Identify and evaluate potential new programs and services to determine cost effectiveness and revenue potential. Develop and pursue new business opportunities. · Collaborate with internal and external entities to improve accessibility standards and quality practice standards to reduce medical costs across the service delivery system

Accomplishments:· Instituted targeted process changes including ongoing metric monitoring and management to achieve goals and drive improvement. · Directed implementation of new technology to support utilization review processes.· Established and maintained excellent rapport within strong network of physicians, hospital personnel, and other external partners. · Fostered a spirit of teamwork to produce the best care possible.· Built and maintain a strong functional team through effective recruiting, training, coaching, team building, and conducting performance appraisals on a timely basis.· Ensure employee development at all levels are planned and executed.

· Orchestrated the development and implementation of departmental policies and procedures. Organized operations with regards to achieving short and long-term departmental goals. · Led and supported the strategic direction and operational oversight for the eligibility and enrollment of fully insured groups and individuals. Managed the successful execution of billing, premium collection, cancellation, reconciliation, and other billing, enrollment, and eligibility operations.· Maintained departmental compliance with company policy, procedures and restrictions.· Performed financial analysis and developed strategies to manage and prevent disputes and improve billing operations and processes. Accomplishments:· Eliminated process inefficiencies via root cause analysis and design workflow to address opportunities identified. Director, Billing Operations, 11/2012 – 11/2016· Orchestrated the development and implementation of departmental policies and procedures. Organized operations with regards to achieving short and long-term departmental goals. · Led and supported the strategic direction and operational oversight for the eligibility and enrollment of fully insured groups and individuals. Managed the successful execution of billing, premium collection, cancellation, reconciliation, and other billing, enrollment, and eligibility operations.· Maintained departmental compliance with company policy, procedures and restrictions.· Performed financial analysis and developed strategies to manage and prevent disputes and improve billing operations and processes. Accomplishments:· Eliminated process inefficiencies via root cause analysis and design workflow to address opportunities identified.

· Directed cross functional teams to execute on plans and proposals. Designed and executed action plans to achieve outcomes. Planned and executed employee development for all staff members. Accomplishments:· Cultivated a work atmosphere that promoted team member support, cooperative collaboration, growth, and development.

· Analyzed the department’s operational efficiency to determine the most effective action plan for improving productivity. Accomplishments · Supervised $5M in open A/R, keeping DSO less than 60 days. Instructed a group of supervisors on team accountability. Boosted team morale to increase productivity during the order review process. Maintained the rate of claim denials below 10%.

· Assisted the Manager with the implementation of action plans and progress toward goals, addressing barriers and challenges, and making adjustments as needed in a supportive, synergistic manner. Accomplishments:· Aided the manager in monitoring open A/R. Utilized data from denial trends to address training issues. Communicated with the state to resolve erroneous denials.

· Supported the design and data retrieval for implementation and optimization of documentation systems needed to promote data integration, improve workflow, and achieve key performance indicators. · Coordinated with doctors, Medi-Cal, California Children’s Services (CCS) and Commercial insurance carriers to complete processes and fulfill the diverse needs of mutual patients. Accomplishments:· Provided wide ranging leadership support to a team of 15 in properly performing procedures for processing prescriptions and prior authorizations for Third Party Carriers. · Promoted from Customer Service roles and received numerous awards including Shield HealthCare President’s Award, Shield HealthCare Special Recognition Awards